Basic Information
| Provider Information | |||||||||
| NPI: | 1861409393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HICKEY | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2650 WARRENVILLE RD | ||||||||
| Address2: | STE 280 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303247911 | ||||||||
| FaxNumber: | 6303247942 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 WARRENVILLE RD | ||||||||
| Address2: | STE 280 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303247911 | ||||||||
| FaxNumber: | 6303247942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085000424 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970002846 | 01 | IN | MEDICAID | OTHER |